Spontaneous Bacterial Peritonitis in Patients with Cirrhosis and Ascites
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Spontaneous bacterial peritonitis
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Spontaneous bacterial peritonitis
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Several influential authors in their recent review on the treatment of patients with cirrhosis [1-3] did not mention spontaneous fungal peritonitis (SFP) as a severe complication of liver cirrhosis. Spontaneous peritonitis (SP) is an infection of ascitic fluid of cirrhotics without an alternative intraabdominal source of infection. If an ascitic fluid culture is performed, the growth of bacteria makes diagnosis of spontaneous bacterial peritonitis (SBP), instead the growth of fungi makes diagnosis of SFP4.
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Due to scarce printed information in our country, the incidence regarding spontaneous peritonitis observed during two years in 76 ascites episodes, found in 63 patients with hepatic cirrhosis, is analysed retrospectively. Thirteen patients (17%), showed spontaneous peritonitis and the relationship man-woman was 5 to 1; 70% of the germs found in the ascites fluid was of enteric origin, mainly Escherichia Coli. In three patients the diagnosis was made by both counting the leucocytes and the clinical symptoms, in spite of the negative culture. There were no significant differences in the presence of humoral complications or alterations when patients appeared with sterile ascites and spontaneous peritonitis, but there were differences with the death rate which was 7.9% (5/63), in the former and 38% (5/13), in infected ascites; 80% of the dead patients showed renal deficiency at the end of the evolution and a relationship with the use of aminoglucosides can not be discarded. The search for spontaneous peritonitis in the cirrhotic patient, as a routine, seems to have the same incidence among as, as the one described in the literature.
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Objective: To evaluate, prospectively, the prevalence, outcome and recurrence of spontaneous bacterial peritonitis (SBP) in cirrhotics with ascites. Setting: Gastroenterology unit at a teaching hospital in Milan and four referring hospitals. Patients and methods: Two hundred and sixty-five consecutive cirrhotics with ascites (208 men, 57 women) were studied. Ascitic fluid tap was obtained at entry to determine total protein concentration, absolute polymorphonuclear (PMN) cell count and to allow bedside culture of both aerobic and anaerobic organisms. Statistical analysis: Mann-Whitney and χ 2 tests. Results: SBP was diagnosed in 24 patients (9%), with enteric organisms involved in 21 patients, culture-negative neutrocytic ascites (CNNA) in 34 (13%) and bacterascites (BA) in 16 (6%)
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The diagnosis of spontaneous bacterial peritonitis (SBP) in patients with ascites is established by definition with a polymorphonuclear (PMN) cell count in the ascitic fluid greater than 0.250 g/l determined via cytological (microscopic) examination. In this study, we correlated the automatically assessed total ascitic nucleated cell count with PMN and determined its predictive value for diagnosis of SBP.Six hundred and eleven consecutive paracenteses of 179 patients with ascites of various aetiologies (liver cirrhosis, hepatocellular carcinoma, peritoneal carcinomatosis, and ascites of other aetiology) were studied retrospectively.The most reliable diagnostic cut-off level was determined for differentiation between SBP and non-SBP via receiver operating characteristics analysis. A total ascitic nucleated cell count less than 1.0 g/l is unlikely to represent SBP (negative predictive value, 95.5%).If ascitic fluid samples with machine-made total ascitic nucleated cell count below 1.0 g/l are not followed by additional laboratory tests, the risk of missing the diagnosis of SBP is low. Applying these criteria we would have classified 51 samples of 611 samples (20 of 179 patients) wrongly using the cut-off value of 1 g/l. On the other hand we would have spared cytologic evaluation in about 63% of paracentesis performed in our hospital. Nevertheless, to insure patient safety, standard laboratory analysis is recommended in circumstances of clinical uncertainty. Thus, patients with first manifestation of ascites should always receive cytologic examination and full diagnostic investigation to exclude other causes of ascites.
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To assess objective incidence of spontaneous bacterial peritonitis (SBP), laboratory findings, effectivity of the treatment and mortality of cirrhotics with ascites and SBP.From June 1994 to June 1999 we performed 692 abdominal paracenteses in 169 cirrhotic patients (mean age 52,63 +/- 8,02 years, mean Child-Pugh score 10,41 +/- 3,02). Culture of ascitic fluid, total leucocyte and granulocyte count in ascites and total protein, albumin and cholesterol levels in ascites and serum were examinated. Diagnosis of SBP was established by criteria of Wilcox and Dismukes.SBP was found in 27 patients by 1st paracentesis (16,0 %), in the other 13 patients by repeated paracentesis (7,7 %). 51 episodes of SBP (7,4 % of all paracenteses) were found in 40 patients. 48 episodes of SBP (94,7 %) were succesfully treated by ATB therapy, 8 patients with SBP died during hospitalization (15,7 %). Patients with SBP had significant lower total protein, albumin and cholesterol levels in serum and ascites compared to patients without ascites infection (all paramethers p <0,01).SBP is a common complication in patients with advanced liver cirrhosis and ascites. Despite of effectivity of ATB therapy the hospital mortality of patients with SBP is high.liver cirrhosis, ascites, spontaneous bacterial peritonitis, mortality.
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In the study 52 patients with decompensated liver cirrhosis and "tense" ascites were included. According to the clinical picture, ascites cultures and the number of polymorphonuclears in cmm of the ascitic fluid, all patients were selected in one of the following groups: 1. group of patients with sterile ascites (28), 2. group of patients with spontaneous peritonitis (16), and 3. group of patients with bacterascites (8). The results have shown that the incidence of spontaneous peritonitis is much higher in the group of "tense" ascites patients than in the group of all patients with ascites, the ratio being 30.7% compared to 6% in all cirrhotic patients with ascites. Spontaneous bacterial peritonitis correlates with increased polymorphonuclears in the ascitic fluid (p less than 0.05), decreased pH values (p less than 0.0), and increased amounts of total proteins in the ascitic fluid (p less than 0.05). The lethality rate in the group of spontaneous peritonitis and sterile ascites was 43.7% and 7.1% respectively. Early diagnosis and, of course, adequate therapy are the main points in spontaneous bacterial peritonitis.
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Objective To investigate the clinical significance of TNFα and hsCRP levels in ascites for diagnosis of cirrhotic patients with spontaneous bacterial peritonitis. Methods Eighty cirrhosis patients with ascites but no clinical symptoms were selected in this study..All patients received the routine test of ascites and ascitic bacterial culture ,.and they were divided into two groups, positive bacterial group and negative bacterial group (n=40, each). TNFα level in serum and ascites were measured by radio -immunity method..HsCRP was measured by ultra ion immune transmisson turbidimetry. Results The levels of TNFα and hsCRP in serum and ascites in positive ascitic fluid culture group was significantly high than those in negative ascitic fluid culture group , especially in ascites (P0.05). There is a positive correlation between TNFα level and hs-CRP level in ascites or serum. After antibiotics treatment for one week , both levels of serum and ascites TNFα and hsCRP were significantly decreased..Conclusion Detection of TNFαand hsCRP in ascites is helpful to the early diagnosis of cirrhotic patients with spontaneous bacterial peritonitis.
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To assess the risk of development of spontaneous bacterial peritonitis in relation to ascitic fluid opsonic activity, routine admission abdominal paracentesis was performed on 119 patients during 141 hospitalizations. Paracentesis was repeated if evidence of peritonitis developed during the hospitalization. The ascitic fluid opsonic activity (0.2 +/- 0.5 log kill) of 24 spontaneously infected specimens was significantly (p less than 0.001) lower than that of the group with sterile portal hypertension-related ascites (0.8 +/- 1.1 log kill), and significantly lower than the group with ascites of miscellaneous type (2.4 +/- 1.0 log kill, p less than 0.001). The C3 and C4 concentrations of the spontaneous peritonitis specimens were also significantly lower than in the specimens from the other groups. Of the 55 patients whose initial sterile ascitic fluid opsonic activity was less than 0.2 log kill, 8 (14.5%) developed spontaneous bacterial peritonitis during the hospitalization; whereas none of the 70 patients with sterile ascitic fluid opsonic activity greater than or equal to 0.2 log kill developed spontaneous peritonitis. This difference in the risk of development of peritonitis was significant (p less than 0.01). Patients with deficient ascitic fluid opsonic activity are predisposed to spontaneous bacterial peritonitis.
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